COVID-19 associated Immune Thrombocytopenic Purpura
Case Report
Gandhi Vandana Thakur(1), Rahul Jadon(2), Rosmy Jose(3)
(1,2) Post Graduate Student, Department of Medicine, Lady Hardinge Medical College
(3) Assistant Professor, Department of Medicine, Lady Hardinge Medical College
ABSTRACT
Novel corona virus was thought primarily to affect the respiratory system. However, the virus has shown myriad of manifestations involving almost all the body systems. How this virus is causing multisystem involvement is yet to be deciphered. Initial recognized hematological manifestation of virus was leucopenia and increased risk of thrombotic events. Now it has been found that thrombocytopenia is also an important manifestation. Whether this is a mere association or causation is yet to be established. We are reporting a case of a patient who presented to us with wet blisters. He was worked up for thrombocytopenic purpura (ITP) with negative extensive evaluation post clinical recovery from Severe COVID-19 disease.
KEY WORDS– Immune thrombocytopenic purpura, COVID-19 disease, steroids.
Immune thrombocytopenic purpura is an acquired disorder which results in fall in platelet count and thus making the individual prone to easy bruising and excessive bleeding. ITP could be primary or secondary. Secondary ITP is associated with an underlying disorder like autoimmune disorders, particularly SLE, and infections, such as HIV, Hepatitis C, Cytomegalovirus, Varicella Zoster, and HTLV. ITP has also emerged as an important complication of covid-19 disease. Diagnosis of ITP is challenging in COVID -19 disease because of presence of multiple confounding factors like sepsis, DIC, drugs.
CASE REPORT
A 42-year-old man with a history of diabetes mellitus presented with fever, cough and dyspnea for 4 days. Blood counts were normal at admission and Chest X-ray showed bilateral basal infiltrates. He was diagnosed with COVID-19 by RT- PCR on oropharyngeal swab. He required non-invasive ventilation for 3 days during hospital stay. Over the next 2 days patient was weaned off oxygen and was discharged on day 10 of admission. At discharge, Platelet counts were 1.8×109 /L.
Patient presented 15 days after discharge with complaints of rash all over the body and bleeding gums. Laboratory examination showed Hb- 13.4 g/dl, TLC- 6400/mm3, platelet count- 4*109/L. Sepsis and Thrombotic thrombocytopenic purpura were excluded. Blood urea-30, creatinine- 0.9mg/dl, CRP- 6.2, LDH- 358, DCT/ICT negative, malaria antigen test/ IgM Typhidot negative, HIV/ Hepatitis B &Hepatitis C Non-reactive, ANA negative, and EBV, HZV by PCR was also negative. Patient was transfused 8 units of random donor platelets for severe thrombocytopenia with bleed. Post-transfusion Platelet count was 13,000. Patient was started on glucocorticoids due to persistent thrombocytopenia with no cause identified despite extensive lab investigation. Patient responded to steroids and platelet counts gradually increased to 1.3lakhs/mm³. Course during hospital stay remained uneventful, thrombocytopenia improved with no further bleed. Patient was discharged on glucocorticoids.
DISCUSSION
Whether COVID 19 is a cause or an association is yet to be established. It can have many reasons. The clinical course of the illness will help to ascertain its etiology. Presence of thrombocytopenia in a symptomatic patient is suggestive of a severe disease. It could be due to sepsis, DIC or drugs.
In our patient advent of thrombocytopenia was post recovery from a severe disease. A plausible explanation could be a post viral marrow suppression. However it should have involved all the cell lines. A selective reduction in platelet count suggested Immune thrombocytopenic purpura (ITP).
Several mechanisms can explain such an occurrence. In COVID autoimmunity can be attributed to molecular mimicry, epitope spreading and cryptic antigenic expression. This has been described in other pathogens also. The molecular mimicry contributes to crossreactive antibodies e.g. platelet surface glycoprotein antibodies.
Due to the novelty of the disease no established treatment protocols were available. So our patient was treated as like any other case of ITP. Our treatment included platelet transfusions and steroid. Post steroid treatment there was improvement in platelet counts.
CONCLUSION
Immune thrombocytopenic purpura (ITP) can occur secondary to covid-19 infections. A systematic approach is essential to diagnose new-onset ITP after excluding several concomitant factors or conditions that can cause thrombocytopeniain covid-19.
In the above, mentioned case, patient was diagnosed as case of ITP secondary to covid-19 infection, after excluding all possible causes of ITP.
REFERENCES
- Bomhof G, Mutsaers PGNJ, Leebeek FWG, Te Boekhorst PAW, Hofland J, Croles FN, Jansen AJG. COVID-19-associated immune thrombocytopenia. Br J Haematol. 2020 Jul;190(2):e61-e64. doi: 10.1111/bjh.16850. Epub 2020 Jun 8. PMID: 32420612; PMCID: PMC7276755.
- Barbara A. Konkle. Disorders of platelets and vessel wall. In: J Larry Jameson, Denis L. Kasper, Dan L. Longo, Anthony S. Fauci, Stephen L. Hauser, Joseph Loscalzo(Eds). Harrisonʾs principle of internal medicine. 20th Mc Graw Hill Education. 2018;p822-829.
- Stepman G, Daley I, Bralts D, et al. A Case of Immune Thrombocytopenia After COVID-19 Infection. Cureus 13(6): e15843.